Womens Health Patient History

Women's Health Patient History
Name
Age
Date

MonthDayYear
Date
1. Describe the current problem that brought you here?
2. When did your problem first begin? place x here months ago or place x here years ago.
3. Was your first episode of the problem related to a specific incident?

YesNo
Please describe and specify date
4. Since that time is it: staying the same place x here getting worse place x heregetting better.
Why or how?
6. Describe previous treatment/exercises
7. Activities/events that cause or aggravate your symptoms. Check all that apply

Sitting greater than minutesWith cough/sneeze/strainingWalking greater than minutesWith laughing/yellingStanding greater than minutesWith lifting/bendingChanging positions (ie. - sit to stand)With cold weatherLight activity (light housework)With triggers -running water/key in doorVigorous activity/exercise (run/weight lift/jump)With nervousness/anxietySexual activityNo activity affects the problemOther
8. What relieves your symptoms?
9. How has your lifestyle/quality of life been altered/changed because of this problem? Social activities (exclude physical activities), specify
Diet/Fluid intake, specify
Physical activity, specify
Work specify
Other
10. Rate the severity of this problem from 0 -10 with 0 being no problem and 10 being the worst
11. What are your treatment goals/concerns?
Since the onset of your current symptoms have you had:

Fever/ChillsMalaise (Unexplained tiredness)Unexplained weight changeUnexplained muscle weaknessDizziness or faintingNight pain/sweatsChange in bowel or bladder functionsNumbness / TinglingOther
Date of Last Physical Exam

MonthDayYear
Date
Tests performed
General Health:

ExcellentGoodAverageFairPoor
Occupation
Hours/week
On disability or leave?
Activity Restrictions
Mental Health - Current level of stress

HighMedLow
Current Psych Therapy

YesNo
Activity/Exercise

None1-2 days/wk3-4 days/wk5+ days/wk
Describe
Have you ever had any of the following conditions or diagnoses? Check all that apply

CancerStrokeEmphysema/Chronic BronchitisHeart ProblemsEpilepsy/SeizuresAsthmaHigh Blood PressureMultiple SclerosisAllergies (list below)Ankle SwellingHead InjuryLatex SensitivityAnemiaOsteoporosisHypothyroid / HyperthyroidLow Back PainChronic Fatigue SyndromeHeadachesSacroiliac/Tailbone painFibromyalgiaDiabetesAlcoholism/Drug ProblemArthritic ConditionsKidney DiseaseChildhood Bladder ProblemsStress FracturesIrritable Bowel SyndromeDepressionRheumatoid ArthritisHepatitis, AIDS/HIVAnorexia/BulimiaJoint ReplacementSexually Transmitted DiseaseSmoking HistoryBone FracturePhysical or Sexual AbuseHearing Loss ProblemsTMJ / Neck PainPelvic PainOther
Surgical / Procedure History

Surgery for your back/spineSurgery for your bladderSurgery for your brainSurgery for your bones/jointsSurgery for your female organsSurgery for your abdominal organsOther
OB/GYN History

Childbirth Vaginal DeliveriesVaginal DrynessEpisiotomyPainful PeriodsC-SectionMenopauseDifficult ChildbirthPainful Vaginal PenetrationProlapse or Organ Falling OutPelvic PainOther
Medications pills injection patch
Start date

MonthDayYear
Date
Reason for taking
Medications pills injection patch
Start date

MonthDayYear
Date
Reason for taking
Medications pills injection patch
Start date

MonthDayYear
Date
Reason for taking
Over the counter -vitamins
Start Date

MonthDayYear
Date
Reason for taking
Over the counter -vitamins
Start Date

MonthDayYear
Date
Reason for taking
Over the counter -vitamins
Start Date

MonthDayYear
Date
Reason for taking
Type a question

Trouble initiating urine streamBlood in urineUrinary intermittent / slow streamPainful uriniationTrouble emptying bladderTrouble feeling bladder urge/fullnessDifficulty stopping the urine streamCurrent laxative useTrouble emptying bladder completelyTrouble feeling bowel / urge / fullnessStraining or pushing to empy bladderConstipation / strainingRecurrent bladder infectionsTrouble holding back gas/fecesConstant urine leakageOther
Frequency of urination: awake hour's blanks times per day, sleep hours blank times per night.
When you have a normal urge to urinate, how long can you delay before you have to go to the toilet? blanks minutes, blank hours, blanksnot at all.
The usual amount of urine passed is: blanks small blank medium Type a label large.
Frequency of bowel movements blanks times per day, blank times per week, or Type a label .
When you have an urge to have a bowel movement, how long can you delay before you have to to the toilet? blanks minutes,blank hours or, Type a label not at all.
If constipation is present describe management techniques
Average fluid intake one glass is 8 OZ or one cup
Of this total how many glasses are caffeinated? blanks glasses per day.
Rate a feeling of organ "falling out" / prolapse or pelvic heaviness / pressure.

None presentTimes per month (specify if related to activity or your period)With standing for min or hoursWith exertion or strainingOther
Bladder leakage - number of episodes - (Skip questions if no leakage / incontinence)

No LeakageTimes per dayTimes per weekTimes per monthOnly with physical exertion / cough
Bowel leakage - number of episodes - (Skip questions if no leakage / incontinence)

No LeakageTimes per dayTimes per weekTimes per monthOnly with physical exertion / cough
On average, how much urine do you leak?

No leakageJust a few dropsWets underwearWets outerwearWets the floor
How much stool do you loose?

No leakageStool stainingSmall amount in underwearComplete emptying
What form of protection do you wear? (Please complete only one)

NoneMinimal protection (Tissue paper / paper towels / panty shields)Moderate protection (absorbent product, maxipad)Maximum protection (Specialty product / diaper)Other
On average how many pad/protection changes are required in 24 hours?
Should be Empty: